Papeles del Psicólogo ISSN: 0214-7823 ISSN: 1886-1415 [email protected] Consejo General de Colegios Oficiales de Psicólogos España

Cervera Pérez, Isabel María; López-Soler, Concepción; Alcántara-López, Mavi; Castro Sáez, Maravillas; Fernández-Fernández, Visitación; Martínez Pérez, Antonia CONSEQUENCES OF CHRONIC INTRA-FAMILY ABUSE IN CHILDHOOD: DEVELOPMENTAL TRAUMA Papeles del Psicólogo, vol. 41, no. 3, 2020, September-, pp. 219-227 Consejo General de Colegios Oficiales de Psicólogos España

DOI: https://doi.org/10.23923/pap.psicol2020.2934

Available in: https://www.redalyc.org/articulo.oa?id=77865632009

How to cite Complete issue Scientific Information System Redalyc More information about this article Network of Scientific Journals from Latin America and the Caribbean, Spain and Journal's webpage in redalyc.org Portugal Project academic non-profit, developed under the open access initiative Papeles del Psicólogo / Psychologist Papers, 2020 Vol. 41(3), pp. 219-227 Articles https://doi.org/10.23923/pap.psicol2020.2934 http://www.papelesdelpsicologo.es http://www.psychologistpapers.com

CONSEQUENCES OF CHRONIC INTRA-FAMILY ABUSE IN CHILDHOOD: DEVELOPMENTAL TRAUMA

Isabel María Cervera Pérez1, Concepción López-Soler2, Mavi Alcántara-López2, Maravillas Castro Sáez2, Visitación Fernández-Fernández2 and Antonia Martínez Pérez2 1Unidad de Salud Mental Comunitaria Huércal-Overa. 2Universidad de Murcia

Los traumas tempranos y repetidos en el contexto de las relaciones de apego impactan de una manera dramática en el desarrollo de los niños/as, generando una diversidad de manifestaciones psicopatológicas complejas, que se incluyen en la última versión de la Clasificación Internacional de Enfermedades (CIE-11) como un diagnóstico nuevo denominado Trastorno por Estrés Postraumático Complejo (TEPT-C). Los objetivos del presente trabajo fueron, por un lado, ofrecer una revisión de la sintomatología postraumática que se desarrolla por la exposición a estos eventos traumáticos, y, por otro, recapitular la evidencia empírica existente del TEPT-C o Trastorno Traumático del Desarrollo (TTD). Los resultados de los estudios revisados confirman la presencia de síntomas extensos y heterogéneos, así como graves alteraciones en la autorregulación (afectiva, cognitiva y conductual), que se ajustan a un TEPT Complejo o TTD, por lo que los datos existentes apoyarían la validez de dichos diagnósticos. Palabras clave: Trauma complejo, Trastorno Traumático del Desarrollo, Maltrato.

Repeated and early attachment trauma has a huge impact on children’s development, producing a wide range of psychopathology, which is included as a new diagnosis called complex posttraumatic stress disorder (CPTSD) in the 11th revision to the World Health Organization’s International Classification of Diseases (ICD-11). The aim of this study is to provide a review of the posttraumatic symptomatology caused by exposure to complex traumatic events and to synthesize the existing empirical evidence on CPTSD and developmental trauma disorder (DTD). The results of the reviewed studies confirm the presence of extensive and heterogeneous symptoms, as well as serious affective, cognitive, and behavioral self- regulation alterations, which correspond to complex PTSD or DTD. Therefore, the current data support the validity of these diagnostic proposals. Key words: Complex trauma, Developmental trauma disorder, Abuse. he concept of trauma refers to the consequences of during childhood act as habitual stressors, and generate exposure to personal experiences that pose a threat to lasting dysfunctions in the main neuroregulatory systems, such T our survival or well-being. Reactions to adverse life as the hypothalamic-pituitary-adrenal axis, and significant situations are very diverse and varied. Allen, Fonagy, and physiopathological consequences (Boeckel, Viola, Daruy- Bateman (2008), proposed a particularly relevant Filho, Martínez, & Grassi-Oliveira, 2017), as well as classification for organizing potentially traumatic events alterations in the development of fundamental brain structures according to the nature and interpersonal involvement of the (Rooij et al., 2020; Teicher & Samson, 2016). This is related stressor. They differentiate between impersonal stressors (e.g., to the presence of deficits in cognitive functioning and natural disasters); interpersonal stressors, when the stressor difficulties in affective and behavioral self-regulation, which comes from the deliberately intentional or reckless behavior of implies a greater risk for developing academic problems and another human being (e.g., accidents, community violence, or multiple psychopathologies (Karam et al., 2014; Perkins & war); and stressors that appear in the context of attachment Graham-Bermann, 2012). relationships (attachment trauma). That is, all situations of In this regard, Cook et al. (2005) noted that such traumas violence and neglect to which a child is exposed in the context are characterized by being chronic, interpersonal, early- of his or her basic primary care (e.g., physical and emotional onset, and affect all areas of functioning. For decades, there abuse, sexual abuse, neglect, abandonment, or direct has been evidence of the inadequacy of the PTSD diagnosis witnessing of violence between parents). to explain the wide range of symptoms resulting from these It has been confirmed that repeated experiences of abuse traumas (Herman, 1992). The percentage of children who develop PTSD, according to official criteria, after exposure to Received: 31 January 2020 - Accepted: 20 April 2020 complex traumas is low and most meet the criteria for many Correspondence: Concepción López-Soler. Universidad de Mur- other diagnoses such as separation anxiety disorder, cia. Facultad de Psicología. Departamento de Personalidad, oppositional defiant disorder, ADHD, or depression Evaluación y Tratamiento Psicológicos. Campus de Espinardo. (Humpherys et al, 2020; Klasen, Gehrke, Metzner, 30100 Murcia. España. E-mail: [email protected] Blotevogel, & Okello, 2013; Scheeringa & Zeanah, 2008),

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various subclinical symptoms or emotional and behavioral PTSD, in addition to serious and persistent problems in the disturbances, which are very frequent in minors in care with regulation of affect; self-beliefs of disability and worthlessness, mental health problems (González-García et al., 2017; feelings of shame, guilt or failure related to the traumatic Martín, González-García, Fernández del Valle, & Bravo, event; as well as difficulties in maintaining relationships and 2020 . feeling close to others. The concept of complex post-traumatic stress disorder Since the mid-90s, studies on the consequences of abuse in (CPTSD), was originally proposed by Herman (1992), with the the family environment have multiplied in the child and aim of providing an alternative diagnosis for survivors of adolescent population, with the diagnosis of CPTSD being repeated and prolonged traumatic exposure, whose most considered as a diagnostic option almost a decade later. severe symptoms were different from those listed in the Abuse is associated with symptoms of re-experiencing, diagnoses for PTSD in the DSM. CPTSD describes, more avoidance, and hyperactivation (PTSD) in minors, however, it completely and appropriately, the psychopathology resulting does not seem that the diagnostic criteria are appropriate for from exposure to complex trauma in adults, and includes a set children either, as few meet all the criteria, and the prevalence of symptoms that reflect serious disturbances in affective, increases when alternative criteria are used (Fernandez, cognitive, and behavioral self-regulation in minors (Courtois, 2014; Martinez, 2015; Scheeringa et al., 2003). 2004). These are expressed in alterations in six domains of Van der Kolk et al. (2005, 2009) postulated developmental functioning: impulse and affect regulation, attention and trauma disorder (DTD), for complex trauma in childhood. DTD awareness, self-perception, relationships with others, includes multiple symptoms in different areas (attachment, somatization, and systems of meaning (Van der Kolk, 2005; biology, affect regulation and self-regulation, awareness, Van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005), behavior control, cognition, and self-concept), which often This new construct was not recognized in the DSM-IV (APA, result from repeated exposure to interpersonal trauma in 1994), nor in its Revised Text (APA, 2000), as a disorder childhood (Cook et al., 2005), (Table 1). (Insert Table 1) other than PTSD, but as “disorder of extreme stress not A central element in the impact of abuse in the first years of life otherwise specified” (DESNOS). Although it gained empirical is based on the alterations in the attachment system between support (Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013; caregiver and child. As indicated by Galán (2020), protection Van der Kolk et al., 2005, Karatzias et al, 2018), it was not and care against external and internal dangers, and for included in the latest version of the DSM (APA, 2013). communication and interpersonal relationships, is decisive. Recently, the ICD-11 (WHO, 2018) has confirmed it as a Studies on CPTSD in minors in care indicate mental health diagnosis, specifying that it must meet the requirements for problems in all the evaluated domains and symptoms of post-

TABLE 1 DIAGNOSTIC CRITERIA DEVELOPMENTAL TRAUMATIC DISORDER

A. Exposure. Has experienced or witnessed multiple or prolonged adverse events for at least one year beginning in early childhood/adolescence, includingA.1. Direct experience or witnessing of repeated and severe episodes of interpersonal violenceA.2. Significant disruptions in basic care as a result of repeated changes or repeated separation from the primary caregiver, or exposure to severe and persistent emotional abuse.

B. Affective and physiological deregulation. Exhibits impaired normal developmental competencies related to arousal regulation, including at least two of the following items: B.1. Inability to modulate, tolerate or recover from extreme emotional states (fear, anger, shame), including severe and prolonged temper tantrums or immobilization B.2 Disturbances to regulation of body functions (e.g., persistent disturbances in sleep, feeding, and sphincter control; hyper/hyporeactivity to touch and sound; disorganized transition between routines). B.3 Diminished consciousness/recognition or dissociation of sensations/emotions/body states (depersonalization, derealization, discontinuity of affective states, emotional numbing, physical analgesia, and difficulty in recognizing emotions). B.4 Difficulty in describing emotions/body states (inner states or communicating needs - hunger or evacuation/elimination).

C. Attentional and behavioral deregulation. Exhibits deterioration of normal developmental skills related to maintaining attention, learning, or coping with stress, including at least three items: C.1 Worrying about the threat, or difficulty in perceiving it, including misinterpretation of safety/danger signals C.2 Impaired capacity for self-protection, including risk-taking or emotionally intense behaviors (risky sexual behaviors, impulsive disregard, underestimation of risk, difficulty understanding rules, for behavioral planning and anticipation of consequences). C.3 Misaligned attempts at self-calming (rocking, other rhythmic movements, compulsive masturbation, substance use). C.4 Habitual (intentional/automatic) or reactive self-harming (cutting, head-butting, burning, pinching) C.5 Inability to initiate/maintain goal-directed behavior (difficulties in planning/completing tasks, abulia).

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traumatic stress, emotional and behavioral difficulties, as well empirical studies available in full text, published in English as risk behaviors and difficulties in daily functioning and Spanish between January 2005 and March 2020. (González-García et al., 2017; Martín et al., 2020). The search terms were: “trauma complejo”, O “trastorno por The aim of this work was to carry out a review of the estrés postraumático complejo”, O “trastorno traumático del empirical research on the psychological consequences of desarrollo”, O “trauma del desarrollo”, O “maltrato infantil” interpersonal trauma in childhood, adolescence, and early in Spanish. “Complex trauma”, OR “complex posttraumatic youth, as well as to analyze the validity of the new diagnosis stress disorder”, OR “complex PTSD”, OR “developmental of complex trauma. trauma disorder”, OR “child maltreatment”, OR “child abuse” in English. In addition, multiple advanced searches were METHOD conducted including the combination of two or more terms A qualitative literature review was conducted, although (e.g., «trauma symptoms or posttraumatic effects AND child some of the proposals for systematic reviews and meta- abuse/childhood neglect»). analysis were taken into account (Moher, Liberati, Tetzlaff, & Any empirical study (randomized control trial (RCT), quasi- Altman, 2009). experimental, cross-sectional, or longitudinal; case-control or cohort) was considered for inclusion if it reported post- Search and selection strategy traumatic symptoms and/or complex effects, or other post- An electronic search of the literature databases in health traumatic consequences, resulting from exposure to traumatic sciences was completed, including: Tripdatabase, events of an interpersonal nature, including sexual, physical, PSICODOC, MedLine, ScienceDirect, PubMed, PsycINFO, and emotional abuse, and neglect, as well as witnessing PsycARTICLES, and Web of Science. It was limited to the domestic, intimate partner, or anti-women violence. The

TABLE 1 DIAGNOSTIC CRITERIA DEVELOPMENTAL TRAUMATIC DISORDER (continuation)

D. Deregulation of the self and relationship. Exhibits deterioration of normal developmental competencies related to personal identity and involvement in relationships, including at least three of the following items:D.1 Intense concern for the safety of the caregiver or significant others (including an early caring attitude toward others) or difficulty in tolerating re-encounter with them after a separation.D.2 Persistent negative self-concept/sense, including feelings of self-hatred, helplessness, feelings of worthlessness, ineffectiveness, or defectivenessD.3 Extreme and persistent distrust, defiant behavior or lack of reciprocity in close adult/peer relationships (includes expectation of being victimized by others).D.4 Physical reactivity or verbal aggression (impulsive, unintentional coercive/manipulative) toward peers/caregivers/other adults.D.5 Inappropriate (excessive/promiscuous) attempts at intimate contact (including but not limited to physical/sexual intimacy) or excessive dependence on peers/adults in pursuit of safety/reassurance. D.6 Impaired ability to regulate empathic activation (lack of empathy, intolerance, or excessive response to the expressions of stress/disturbance of others)

E. Post-traumatic Symptom Spectrum. Exhibits at least one symptom in at least two of three clusters (B, C, and D) of PTSD symptoms

F. Duration of the disorder (Criteria B, C, D, and E): at least 6 months

G. Difficulties or functional impairment. Causes clinically significant discomfort or impairment/disability in at least two areas: SCHOOL: low performance or dropout, discipline problems, non-attendance, conflicts with teachers, learning problems (not explained by neurological disorder). FAMILY: conflict, avoidance/passive, running away, detachment, finding substitutes, attempts to physically/emotionally harm family members, failure to meet family responsibilities. PEER GROUP: isolation, persistent physical/emotional conflict, violence or unsafe acts, age-inappropriate interaction/affiliation styles LEGAL: arrests/recidivism, convictions/prison, violation of probation, increase in seriousness of crime, crimes against others, disregard for law or moral conventions. HEALTH: physical illness or problems that cannot be explained by physical injury or degeneration, including digestive, neurological (conversive symptoms, analgesia), sexual, immune, cardiopulmonary, proprioceptive/sensory, severe headaches or chronic pain/fatigue. VOCATIONAL (applicable to youth seeking employment or working): disinterest in work/vocational training, inability to obtain/maintain employment, persistent conflict with co-workers or supervisors, underemployment in relation to skills, inability to advance.

Note: Taken from Van der Kolk et al. (2009)

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emphasis was on early and long-term experiences of abuse by events, including physical and sexual assault, which primary caregivers. In addition, the representative sample had contributes to the increased rate of diagnosis of PTSD and to be between the ages of 0 and 25 (N ≥ 30). other internalizing and externalizing symptoms (Alcántara, Grey literature (e.g., theses, book chapters, letters to the López-Soler, Castro, & López, 2013; Graham-Bermann et al., editor, and theoretical/opinion papers), systematic reviews, 2012). In children and adolescents with severe and chronic and meta-analyses were all excluded. trauma, a high comorbidity of other alterations different from An initial compilation of all article titles and abstracts was PTSD was observed, which are part of the dysregulation made, and a full text selection was carried out for all results symptoms present in CPTSD, related to deficits in executive that met the inclusion criteria. functions (Op den Kelder et al. (2017). Studies comparing minors with a history of trauma, Data Extraction according to DTD exposure criteria, with other types of The following data were extracted from each study: (a) traumatic experiences, confirmed substantial clinical number of participants; (b) age range; (c) type of childhood differences between the two groups, with the former having a trauma; (d) presence of trauma or multiple traumas repeated higher probability of alterations typical of childhood CPTSD or over time; and (e) effects of trauma and diagnosis. DTD (Cloitre et al., 2009; McClelland et al., 2009; Stolbach et al., 2009; Stolbach et al., 2013; Zhang, Zhang, & Ding, RESULTS 2019). Children in care compared to children who have In all the studies reviewed, the results showed the presence suffered equivalent abuse, but are not separated from their of symptoms compatible with complex post-traumatic reactions parents or one of their parents, also develop complex trauma, in a large percentage of the children who had suffered some but the evolution and complications of this trauma are more serious form of abuse during childhood. Spinazzola et al. severe in children in care (Zhang et al., 2019). Spinazzola et (2005), López-Soler (2008), Van Meter, Handley, and al. (2018), reported that DTD and PTSD are associated with Cicchetti (2020), and Villalta et al. (2020), specifically assault and/or physical abuse, family violence, emotional reported alterations in the regulation of affect and abuse, neglect, and disabled caregivers. Teenage victims of interpersonal relationships, core symptoms in complex trauma. sexual abuse showed high prevalence of DTD as well as PTSD In addition, López-Soler (2008) found that hopelessness and (Villalta et al., 2020). Studies confirm that both types of post- ambivalence in relationships also predominated, which is traumatic reactions present high comorbidity (See Table 2). related to attachment problems. Other authors reported alterations, symptomatology, or joint diagnosis of PTSD and CONCLUSIONS DTD (Spinazzola, Van der Kolk, & Ford, 2018; Stolbach et Mistreatment, abuse, and abandonment during childhood al., 2013; Van der Kolk, Ford, & Spinazzola, 2019), while can be considered traumatic events that interrupt the normal other research detected serious emotional and/or behavioral cerebral development and that can even produce alterations in different groups of minors exposed to intra-family considerable modifications in some cerebral structures. These abuse from early stages (López-Soler et al, 2012; Wamser- neurobiological effects seem to play a relevant role, together Nanney & Vandenberg, 2013), as well as internalizing with other environmental and genetic factors, in the later and/or externalizing problems (Geerson, et al., 2011; development of several psychopathologies, both in the short Graham-Bermann, Castor, Miller, & Howell, 2012; Lansing, and long term. Plante, Beck, & Ellenberg, 2018; Martin et al., 2020; Tarren- The results of the studies reviewed support the enormous Sweeney, 2013). In all of these and in other works (e.g., traumatic potential of events occurring in the everyday context Kiesel et al., 2014), difficulties in daily functioning in different of attachment relationships, which involve non-existent or areas (school, leisure, peer relations, etc.) were also inappropriate care and protection of minors by responsible observed. This problem was expressed throughout childhood adults. Research has found evidence that these types of to early youth (Beal et al., 2018; Porto-Faus, Leite de Moraes, traumatic events generate, in both adults and minors, a Reichenheim, Borges da Matta, & Taquette, 2019) or adult diversity of psychopathological manifestations that exceed the life (Delgi-Espositi, Pinto, Humpherys, Sale, & Bowes, 2020), exclusive symptomatology of PTSD, and that affect affective, in people who had suffered different types of abuse. cognitive, and behavioral regulation. Wamser-Nanney and Vandenberg (2013), compared With the aim of improving the diagnosis of the impact of symptoms in minors exposed to interpersonal violence, who complex traumas, two new diagnostic proposals emerged, had suffered interruptions in protection and care, with those that of CPTSD and DTD, equivalent to complex PTSD, but exposed to other types of trauma, and confirmed that the first specific to the child population. Since then, abundant scientific group presented more behavioral problems such as anxiety, evidence has accumulated to support the consistency, validity, depression, dissociative symptoms, anger/aggression and and clinical utility of these diagnoses (Achterhof, Huntjens, difficulties of a sexual nature. Meewisse, & Kiers, 2019; Ford, Spinazzola, van der Kolk, & Research on children exposed to violence against their Grasso, 2014), which has led to the inclusion of complex mothers by their partners or ex-partners has shown an PTSD in the ICD-11 (WHO, 2018). increased risk of becoming victims of other serious traumatic In minors, the diagnosis of DTD allows us to verify the impact

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TABLE 2 STUDIES REVIEWED ON SYMPTOMS COMPATIBLE WITH PTSD OR DTD IN THE INFANT POPULATION

Study Sample Results

Spinazzola et al. (2005) N =1699 Over 50% alterations 6 CPTSD domains: affect regulation, information processing, self- Age: 2-21 years, NCTSN. concept, behavior, interpersonal relations, and biology. Multiple victims/prolonged severe trauma (physical and/or psychological abuse, exposure to domestic violence, sexual abuse or neglect) at an early stage

López Soler (2008) N=44 Over 50% complex PTSD indicators: alterations in affect/impulses, awareness, in the Age: 6-15 years old. relationship with caregivers/educators/peers, distortions in self-perception/perception of Children in care who had suffered repeated experiences abusers, depression, anxiety, self-harm, substance abuse, risk behaviors, and hopelessness. of domestic abuse.

Cloitre et al. (2009) N = 152 (clinical) Exposure to cumulative trauma predicted the complexity of the symptoms. Age: 3-17 years old. Victims of sexual abuse, neglect, emotional and physical abuse, witnessing partner violence. They lived with substitute caregivers.

Kiesel et al. (2009) N = 4272 G1 greater number of PTSD symptoms, emotional and behavioral difficulties, risk behaviors, Age: 0-18 years old. and functional impairment. Illinois children in care services. 1. Children suffered trauma (≥2) perpetrated by primary caregivers. 2. They had experienced trauma that did not meet all of the above criteria.

Greeson et al. (2011) N=2251 Exposure to complex trauma predicted behavioral problems, internalizing, PTSD symptoms, Age: 0-21 years old. and various clinical diagnoses. Children in care who had experienced 5.8 (average) complex traumatic events.

López Soler et al. (2012) N=42 High trait sensitivity, anxiety, and anger; depressive symptoms; and low anger control. Age: 6-16 years old Children in care, exposed to situations of chronic intra-family abuse.

Graham-Bermann et al. N=120 38% of minors exposed to gender violence suffered other traumatic events within the family (2012) Age: 4-6 years old (physical and sexual abuse). They presented more PTSD symptoms and Gender violence and other types of domestic violence. internalizing/externalizing problems.

Alcantara et al. (2013) N=91 Age: 6 -17 years old Internalizing (anxiety/depression, withdrawal, somatic complaints) and externalizing problems Gender violence. (aggression)

Stolbach et al. (2013) N=214 Age: 3-17 years old. 31% G1 met full DTD diagnostic criteria, versus 6% G2. 1. Children with A-DTD criteria. 97% G1 met PTSD criteria 2. Controls: did not meet these criteria. Significant inter-group differences in 11 of 15 DTD symptoms.

Tarren-Sweeney (2013) N=347 Age: 4-11 years old Attachment problems. Children in care, different degrees of mistreatment. 35% subclinical internalizing/externalizing alterations; 20% complex symptoms related to attachment and trauma. Wamser-Nanney & N=336 Vandenberg (2013) Age: 3-18 years old. G1 more behavioral problems, anxiety, depression, dissociative symptoms, anger/aggression, 1. Children with A-DTD criteria and sexual difficulties. No significant inter-group PTSD differences. 2. Control (no A-DTD criteria)

Kiesel et al. (2014) N=1823 Age: 0-20 years old. G1 increased risk of occurrence/severity of clinical/functional problems: PTSD, dissociation, NCTSN children in care. depression, attachment problems, academic problems, ADHD, suicide/self-harm, substance 1. Victims of trauma perpetrated by primary abuse, sexualized behaviors, and criminality caregivers 2. Trauma not perpetrated by primary figures.

Hengartner et al. (2015) N=1170 Age: 20-41 years old Anxious personality associated with emotional abuse; extraversion, emotional abandonment, Exposed to a traumatic event in childhood and affability to emotional neglect.

Carliner et al. (2016) N=9956 Teenagers: 13-18 years old. Sexual abuse, emotional neglect, and adverse home environment predicted symptoms of Domestic violence depression, PTSD, and self-injurious behavior.

Marshall (2016) N=2899 Girls: 13-18 years old. Potentially traumatic events in childhood were associated with the risk of illicit drug use and various disorders in adolescence.

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of events in attachment that determine problems in achieving international fostering and adoption, as the whole system of normal evolutionary competences related to central aspects of emotional relationships is modified. The understanding of the children’s development, and prevents them from complex trauma allows and requires the generation of a functioning satisfactorily in the different areas of their life and specific reference framework in the psychological treatment of mental well-being. children exposed to abuse and neglect by their caregivers. The implications for the evaluation, diagnosis, and improvement of the efficacy and effectiveness of psychological CONFLICT OF INTEREST treatments are very important. The impact is not only clinical, There is no conflict of interest. but also covers crucial aspects of attachment and conditions of care and adoption, since the previous emotional ruptures and new conditions of care and protection, as well as the post- REFERENCES traumatic conditions of the child, allow a better understanding References marked with an asterisk (*) contain the studies of the difficulties in the procedures of national and included in the review:

TABLE 2 STUDIES REVIEWED ON SYMPTOMS COMPATIBLE WITH PTSD OR DTD IN THE INFANT POPULATION (continuation)

Study Sample Results

Wong et al. (2016) N=389 Interpersonal violence was associated with externalizing symptoms and PTSD symptoms. They Age: 13-25 years old. were positively related to each other and developed together over time. Homeless children.

Barboza et al. (2017) N=280 Living a traumatic event during puberty predicted anxiety disorders, during pre-puberty Age: 8-15 years old. depressive disorders, and that the trauma would be recurrent and/or during primary education Abused youths in care predicted PTSD diagnosis.

Hyland et al. (2017) N=171 persons exposed to trauma Validation of the ICD-11 PTSD-CPTSD, through criterion variables.

Op den Kelder et al. N=119 Young people exposed to complex traumas are more deficient in executive functions than Age: 9 -17 years old. young people with PTSD or control. PTSD group (n=41); complex trauma group (n=38) and control group (n = 40 ) Beal et al. (2018) N=151 Family violence was associated with poorer psychological well-being and quality of life, family Age: 16-22 years old instability, and tobacco/marijuana use. Children in care, victims of unexpected tragedies, instability, or family violence Lansing et al. (2018) N=107 Physical abuse made internalizing and externalizing syndromes more likely in boys; and Age: 16-18 years old. emotional abuse made externalizing syndromes more often in girls. Domestic violence. Spinazzola et al. (2018) N=236 DTD is associated with family/community violence and caregiver disability; PTSD is associated Age: 7-18 years old. with assault/physical abuse. Multicultural sample. Community/intra-family family violence. Porto-Faus et al. (2019) N=699 Emotional and sexual abuse and physical neglect increase adolescent violence/delinquency. Age: 15-18 years old. Physical abuse and emotional neglect are risk factors. Domestic violence. Van der Kolk et al. (2019) N=236 PTSD and DTD are highly comorbid. DTD comorbidity with panic disorder, conduct disorder, Age: 7-18 years old.Community/family violence; other SAD, and ADHD. PTSD comorbidity with major depression and GAD. traumas Zhang et al. (2019) N=382 At the beginning of the abandonment there are no emotional or behavioral differences. Later, Age: 13-18 years old. abandoned children develop DTD. Chinese children (182 abandoned by their parents and 200 living with them). Delgi-Espositi et al. (2020) N=8088 Experiencing multiple types of abuse increased the risk of antisocial behavior in childhood and Longitudinal study (measurement from 7 to 50 years old) adulthood. Villalta et al. (2020) Intra-family abuse

N=99 girls, victims of sexual assault 59% met criteria for PTSD; 41% DTD, which correlated with PTSD, emotional dysregulation, Van Meter et al. (2020) Age: 13-17 years old. negative self-concept, and interpersonal problems.

N=416 Abuse was associated with greater emotion-centered conflict resolution and less problem- Age: 5-12 years old centered resolution. Emotion-centered coping, higher risk for externalizing behaviors. (197 abused; 219 not abused) Multicultural sample.

Note: NCTSN: The National Child Traumatic Stress Network; G1: Group 1; G2: Group 2; SAD: Separation Anxiety Disorder; GAD: Generalized Anxiety Disorder

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226 ISABEL MARÍA CERVERA PÉREZ, CONCEPCIÓN LÓPEZ-SOLER, MAVI ALCÁNTARA-LÓPEZ, Articles MARAVILLAS CASTRO SÁEZ, VISITACIÓN FERNÁNDEZ-FERNÁNDEZ AND ANTONIA MARTÍNEZ PÉREZ

*Stolbach, B. C., Minshew, R., Rompala, V., Dominguez, R. Spinazzola, J. (2005). Disorders of extreme stress: The Z., Gazibara, T., & Finke, R. (2013). Complex trauma empirical foundation of a complex adaptation to trauma. exposure and symptoms in urban traumatized children: A Journal of Traumatic Stress, 18, 389-399. doi: preliminary test of proposed criteria for Developmental 10.1002/jts.20047 Trauma Disorder. Journal of Traumatic Stress, 26, 1-9. doi: *Van Meter, F., Handley, E.D., & Cicchetti, D. (2020). The 10.1002/jts.21826 role of coping strategies in the pathway between child *Tarren-Sweeney, M. (2013). An investigation of complex maltreatment and internalizing and externalizing attachment and trauma-related symptomatology among behaviors. Child Abuse & Neglect, 101,104323 doi: children in foster and kinship care. Child Psychiatry & 10.1016/j.chiabu.2019.104323 Human Development, 44(6), 727-741. doi: *Villalta, L., Khadr, S., Chua, K., Kramer, T., Clarke, V., 10.1007/s10578-013-0366-x. Viner, R.M., … Smith, P. (2020). European Journal of Teicher, M.H., & Samson.J.A. (2016). Annual research Psychotraumatology, 11(1), 1710400. doi: review: Enduring neurobiological effects of childhood 10.1080/20008198.2019.1710400. abuse and neglect. Journal of Child Psychology and *Wamser-Nanney, R., & Vandenberg, B.R. (2013). Empirical Psychiatry, 57(3), 241-266. doi: 10.1111/jcpp.12507 support for the definition of a complex trauma event in Van der Kolk, B.A. (2005). Developmental trauma disorder: children and adolescents. Journal of Traumatic Stress, 26, toward a rational diagnosis for children with complex 671-678. doi: 10.1002/jts.21857 trauma histories. Psychiatric Annals, 35(5), 401-408. doi: 10.3928/00485713-20050501-06 World Health Organization (2018). International Statistical *Van der Kolk, B., Ford, J.D., & Spinazzola, J. (2019). Classification of Diseases and Related Health Problems Comorbidity of developmental trauma disorder (DTD) and 11th Revision (ICD-11). Retrieved from post-traumatic stress disorder: Findings for the DTD field https://www.who.int/classifications/icd/en/ trial. European Journal of Psychotraumatology, 10(1), *Wong, C.F., Clark, L.F., & Marlotte, L. (2016). The Impact 1562841. doi: 10.1080/20008198.2018.1562841 of Specific and Complex Trauma on the Mental Health of Van der Kolk, B.A., Pynoos, R.S., Cichetti, D., Cloitre, M., Homeless Youth. Journal of Interpersonal Violence, 31(5), D’Andrea, W., Ford, J.D., … Teicher, M. (2009). Proposal 831-854. doi: 10.1177/0886260514556770 to include a developmental trauma diagnosis for children * Zhang, Y., Zhang, J., & Ding, C. (2019). Investigating the and adolescents in DSM V. Retrieved from association between parental absence and developmental www.traumacenter.org. trauma disorder symptoms. Journal of Traumatic Stress, Van der Kolk, B.A., Roth, S., Pelcovitz, D., Sunday, S., & 32(5), 733-741. doi: 10.1002/jts.22446

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